Healthcare Provider Details

I. General information

NPI: 1780812917
Provider Name (Legal Business Name): QUINCY VIDAURI LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SW 160TH ST
BURIEN WA
98166-3025
US

IV. Provider business mailing address

432 MAIN AVE N
NORTH BEND WA
98045-8237
US

V. Phone/Fax

Practice location:
  • Phone: 206-242-8211
  • Fax:
Mailing address:
  • Phone: 425-802-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60076727
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMA60076727
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: